HPB Surgery http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Surgery for Cystic Pancreatic Lesions in the Post-Sendai Era: A Single Institution Experience Thu, 19 Mar 2015 13:36:39 +0000 http://www.hindawi.com/journals/hpb/2015/847837/ Introduction. The management of cystic pancreatic lesions has changed in recent years as a result of increasing knowledge of their biological behaviour, better diagnostic options, and international guidelines. Methods. Retrospective analysis of a cohort of 86 patients operated for cystic pancreatic lesions during a seven-year period (2007–2014). Results. Final histopathology revealed 53 intraductal papillary mucinous neoplasms (19 branch duct IPMNs, 15 mixed type IPMNs, and 19 main duct IPMNs), 14 serous and 13 mucinous cystic neoplasms, 3 solid pseudopapillary neoplasms, and 3 other lesions. 4 cases displayed high grade intraepithelial neoplasia and 2 cases displayed invasive cancer. A pylorus-preserving partial duodenopancreatectomy was carried out in 27 patients, a total pancreatectomy was carried out in 9 patients, a left resection was carried out in 42 patients, and segmental resections and enucleations were carried out in 4 patients each. Overall postoperative morbidity and mortality were 40% and 2.3%, respectively. The preoperative diagnosis of a specific cystic tumor was accurate in 79% of patients and 9 patients (10%) could have avoided surgery with the correct preoperative diagnosis. Conclusion. Cystic pancreatic lesions are still a diagnostic challenge, requiring a dedicated multidisciplinary approach. The rate of malignancy is relatively small, whereas postoperative morbidity is substantial, underscoring the importance of adequate patient selection considering both the risk of surgery and the long term risk of malignancy. Jörg Kleeff, Christoph Michalski, Bo Kong, Mert Erkan, Susanne Roth, Jens Siveke, Helmut Friess, and Irene Esposito Copyright © 2015 Jörg Kleeff et al. All rights reserved. The Impact of Changed Strategies for Patients with Cholangiocarcinoma in This Millenium Wed, 18 Feb 2015 11:38:14 +0000 http://www.hindawi.com/journals/hpb/2015/736049/ Background. Cholangiocarcinoma is a cancer with a poor prognosis. In this millennium there are new diagnostic and therapeutic strategies for these patients. Aim. The aim of this study was to find if these changes influenced survival of individuals with proximal cholangiocarcinoma. Material. 627 individuals with a diagnosis of cholangiocarcinoma (not including distal common duct cancer) during the period from 2000 to 2011 were registered in Sweden’s Western Region. The material was divided into three consecutive time periods. Results. The overall survival curves for individuals with cholangiocarcinoma improved over the three time periods . Median survival increased from 2.6 months in the first period (2000–2003) to 3.6 months in the final four years (2008–2011). Patients with perihilar cholangiocarcinoma (PHC) had longer median survival than those with intrahepatic cholangiocarcinoma (IHC): 6.8 versus 3.2 months . An improvement in the survival curves over time was seen for those with IHC but not for patients with PHC . Nine percent of the patients with IHC had potential curative surgical therapy. The three-year survival rate after liver resection for patients with IHC was 35% and 60% after liver transplantation. Among patients with PHC, 15.3% had potential curative bile duct resection with a concomitant liver resection and 6.1% bile duct resection alone. The three-year survival rate for these two groups was 32% and 20%, respectively. Conclusion. Overall survival for individuals with PHC was better than for those with IHC. Over time survival in IHC patients improved but not in those with PHC. Per Lindnér, Magnus Rizell, and Lo Hafström Copyright © 2015 Per Lindnér et al. All rights reserved. Laparoscopic versus Open Liver Resection: Differences in Intraoperative and Early Postoperative Outcome among Cirrhotic Patients with Hepatocellular Carcinoma—A Retrospective Observational Study Thu, 04 Dec 2014 12:07:55 +0000 http://www.hindawi.com/journals/hpb/2014/871251/ Introduction. Laparoscopic liver resection is considered risky in cirrhotic patients, even if minor surgical trauma of laparoscopy could be useful to prevent deterioration of a compromised liver function. This study aimed to identify the differences in terms of perioperative complications and early outcome in cirrhotic patients undergoing minor hepatic resection for hepatocellular carcinoma with open or laparoscopic technique. Methods. In this retrospective study, 156 cirrhotic patients undergoing liver resection for hepatocellular carcinoma were divided into two groups according to type of surgical approach: laparoscopy (LS group: 23 patients) or laparotomy (LT group: 133 patients). Perioperative data, mortality, and length of hospital stay were recorded. Results. Groups were matched for type of resection, median number of nodules, and median diameter of largest lesions. Groups were also homogeneous for preoperative liver and renal function tests. Intraoperative haemoglobin decrease and transfusions of red blood cells and fresh frozen plasma were significantly lower in LS group. MELD score lasted stable after laparoscopic resection, while it increased in laparotomic group. Postoperative liver and renal failure and mortality were all lower in LS group. Conclusions. Lower morbidity and mortality, maintenance of liver function, and shorter hospital stay suggest the safety and benefit of laparoscopic approach. Antonio Siniscalchi, Giorgio Ercolani, Giulia Tarozzi, Lorenzo Gamberini, Lucia Cipolat, Antonio D. Pinna, and Stefano Faenza Copyright © 2014 Antonio Siniscalchi et al. All rights reserved. Risk Factors Associated with Reoperation for Bleeding following Liver Transplantation Thu, 20 Nov 2014 09:25:30 +0000 http://www.hindawi.com/journals/hpb/2014/816246/ Introduction. This study’s objective was to identify risk factors associated with reoperation for bleeding following liver transplantation (LTx). Methods. A retrospective study was performed at a single institution between 2001 and 2012. Operative reports were used to identify patients who underwent reoperation for bleeding within 2 weeks following LTx (operations for nonbleeding etiologies were excluded). Results. Reoperation for bleeding was observed in 101/928 (10.8%) of LTx patients. The following characteristics were associated with reoperation on multivariable analysis: recipient MELD score (OR 1.06/MELD unit, 95% CI 1.03, 1.09), number of platelets transfused (OR 0.73/platelet unit, 95% CI 0.58, 0.91), and aminocaproic acid utilization (OR 0.46, 95% CI 0.27, 0.80). LTx patients who underwent reoperation for bleeding had a longer ICU stay (5 days ± 7 versus 2 days ± 3, ) and hospitalization (18 days ± 9 versus 10 days ± 18, ). The risk of death increased in patients who underwent reoperation for bleeding (HR 1.89, 95% CI 1.26, 2.85). Conclusion. Reoperation for bleeding following LTx was associated with increased resource utilization and recipient mortality. A lower threshold for intraoperative platelet transfusion and antifibrinolytics, especially in patients with high lab-MELD score, may decrease the incidence of reoperation for bleeding following LTx. Maxwell A. Thompson, David T. Redden, Lindsey Glueckert, A. Blair Smith, Jack H. Crawford, Keith A. Jones, Devin E. Eckhoff, Stephen H. Gray, Jared A. White, Joseph Bloomer, and Derek A. DuBay Copyright © 2014 Maxwell A. Thompson et al. All rights reserved. Primary Leiomyoma of the Liver: A Review of a Rare Tumour Wed, 19 Nov 2014 08:50:51 +0000 http://www.hindawi.com/journals/hpb/2014/959202/ Context. Primary leiomyoma of the liver is a rare tumour with uncertain pathogenesis with similar presentation with other tumours of the liver. Little is known about its clinical course. Objectives. To review the literature for case reports of primary leiomyoma of the liver. Methods. Extensive literature search was carried out for case reports of primary leiomyoma of the liver. Results. A total of 36 cases of primary leiomyoma of the liver were reviewed. The mean age of presentation is 43 years with slight female sex affectation; females accounted for 55.6% of the cases reported in the literature. The average size of the tumour is 8.7 cm. 34.4% of the cases reviewed were incidental finding with the mean follow-up time of 33 months with most cases reporting no evidence of disease. Conclusions. Primary leiomyoma of the liver is very rare tumour with complex pathogenesis which remains largely unknown. Imaging of the tumour does not allow for a tissue specific diagnosis; hence histological review of the tissue specimen and immunohistochemical stains are imperative for diagnosis. Surgical resection is both diagnostic and curative. The diagnosis of primary leiomyoma of the liver should be considered as a differential in the management of liver tumours. Ayodeji Oluwarotimi Omiyale Copyright © 2014 Ayodeji Oluwarotimi Omiyale. All rights reserved. Use of Pharmacologic Agents for Modulation of Ischaemia-Reperfusion Injury after Hepatectomy: A Questionnaire Study of the LiverMetSurvey International Registry of Hepatic Surgery Units Wed, 12 Nov 2014 07:09:48 +0000 http://www.hindawi.com/journals/hpb/2014/437159/ Objectives. This study is a questionnaire survey on the use of pharmacological agents to modify liver ischaemia-reperfusion (IR) injury in patients undergoing hepatectomy for colorectal liver metastases with the target population being those units participating in the LiverMetSurvey international registry. Methods. Members of LiverMetSurvey were sent an online questionnaire using SurveyMonkey comprising ten questions on the use of pharmacological agents to modulate hepatic IR injury in the perioperative period after hepatectomy. The questionnaire was sent to 446 clinicians registered with the LiverMetSurvey. There were 83 (19%) respondents. Results. Fifty-two (77% of 68 respondents to this question) never used pharmacological agents to modify liver IR injury during hepatectomy. Thirteen (19%) used pharmacological agents selectively. Three (4%) used these routinely. N-Acetylcysteine was the most widely used pharmacological agent with equal distribution of use around intraoperative and postoperative periods. Conclusions. This is believed to be the first survey on the use of pharmacological agents to modify liver IR injury. The target population is clinicians involved in liver resection. The results show that pharmacological modulation is used by only a minority of respondents to this questionnaire and that when this treatment is selected, N-acetylcysteine is the most frequently used. Santhalingam Jegatheeswaran, Saurabh Jamdar, Thomas Satyadas, Aali J. Sheen, Rene Adam, and Ajith K. Siriwardena Copyright © 2014 Santhalingam Jegatheeswaran et al. All rights reserved. Iatrogenic Biliary Injuries: Multidisciplinary Management in a Major Tertiary Referral Center Mon, 10 Nov 2014 11:25:26 +0000 http://www.hindawi.com/journals/hpb/2014/575136/ Background. Iatrogenic biliary injuries are considered as the most serious complications during cholecystectomy. Better outcomes of such injuries have been shown in cases managed in a specialized center. Objective. To evaluate biliary injuries management in major referral hepatobiliary center. Patients & Methods. Four hundred seventy-two consecutive patients with postcholecystectomy biliary injuries were managed with multidisciplinary team (hepatobiliary surgeon, gastroenterologist, and radiologist) at major Hepatobiliary Center in Egypt over 10-year period using endoscopy in 232 patients, percutaneous techniques in 42 patients, and surgery in 198 patients. Results. Endoscopy was very successful initial treatment of 232 patients (49%) with mild/moderate biliary leakage (68%) and biliary stricture (47%) with increased success by addition of percutaneous (Rendezvous technique) in 18 patients (3.8%). However, surgery was needed in 198 patients (42%) for major duct transection, ligation, major leakage, and massive stricture. Surgery was urgent in 62 patients and elective in 136 patients. Hepaticojejunostomy was done in most of cases with transanastomotic stents. There was one mortality after surgery due to biliary sepsis and postoperative stricture in 3 cases (1.5%) treated with percutaneous dilation and stenting. Conclusion. Management of biliary injuries was much better with multidisciplinary care team with initial minimal invasive technique to major surgery in major complex injury encouraging early referral to highly specialized hepatobiliary center. Ibrahim Abdelkader Salama, Hany Abdelmeged Shoreem, Sherif Mohamed Saleh, Osama Hegazy, Mohamed Housseni, Mohamed Abbasy, Gamal Badra, and Tarek Ibrahim Copyright © 2014 Ibrahim Abdelkader Salama et al. All rights reserved. The Interaction between Diabetes, Body Mass Index, Hepatic Steatosis, and Risk of Liver Resection: Insulin Dependent Diabetes Is the Greatest Risk for Major Complications Thu, 14 Aug 2014 08:48:31 +0000 http://www.hindawi.com/journals/hpb/2014/586159/ Background. This study aimed to assess the relationship between diabetes, obesity, and hepatic steatosis in patients undergoing liver resection and to determine if these factors are independent predictors of major complications. Materials and Methods. Analysis of a prospectively maintained database of patients undergoing liver resection between 2005 and 2012 was undertaken. Background liver was assessed for steatosis and classified as <33% and ≥33%. Major complications were defined as Grade III–V complications using the Dindo-Clavien classification. Results. 504 patients underwent liver resection, of whom 56 had diabetes and 61 had steatosis ≥33%. Median BMI was 26 kg/m2 (16–54 kg/m2). 94 patients developed a major complication (18.7%). BMI ≥ 25 kg/m2 () and diabetes () were associated with steatosis ≥33%. Only insulin dependent diabetes was a risk factor for major complications (). Age, male gender, hypoalbuminaemia, synchronous bowel procedures, extent of resection, and blood transfusion were also independent risk factors. Conclusions. Liver surgery in the presence of steatosis, elevated BMI, and non-insulin dependent diabetes is not associated with major complications. Although diabetes requiring insulin therapy was a significant risk factor, the major risk factors relate to technical aspects of surgery, particularly synchronous bowel procedures. M. G. Wiggans, J. T. Lordan, G. Shahtahmassebi, S. Aroori, M. J. Bowles, and D. A. Stell Copyright © 2014 M. G. Wiggans et al. All rights reserved. Surgical Strategy for Isolated Caudate Lobectomy: Experience with 16 Cases Tue, 01 Jul 2014 09:35:26 +0000 http://www.hindawi.com/journals/hpb/2014/983684/ Introduction. Surgical resection is the most effective treatment for neoplasm in the caudate lobe. Isolated caudate lobectomy is still a challenge for hepatobiliary surgeons. No widely accepted surgical strategy for the procedure has been developed yet. Objective. To get a better understanding of isolated caudate lobectomy and to optimize the procedure. Materials and Methods. 16 cases of isolated caudate lobectomy were reviewed to summarize the surgical experience. Results. All the 16 cases of isolated caudate lobectomy were carried out successfully, among which left side approach was adopted in two cases (12.5%), right side approach in three cases (18.75%), and both sides approach in 11 cases (68.75%). No severe complications occurred. Conclusion. The majority of neoplasms confined to the caudate lobe can be resected safely by left and right side approach with proper anatomic surgical procedure, usually in the sequence of mobilization, outflow control, inflow control, and division of the hepatic parenchyma. Fully mobilizing the caudate lobe from the inferior vena cava (IVC) is of great importance. Division of the retrohepatic ligament and the venous ligament facilitated the procedure. Gendong Tian, Qiong Chen, Yuan Guo, Mujian Teng, and Jie Li Copyright © 2014 Gendong Tian et al. All rights reserved. The Association between Survival and the Pathologic Features of Periampullary Tumors Varies over Time Tue, 01 Jul 2014 09:32:54 +0000 http://www.hindawi.com/journals/hpb/2014/890530/ Introduction. Several histopathologic features of periampullary tumors have been shown to be correlated with prognosis. We evaluated their association with mortality at multiple time points. Methods. A retrospective chart review identified 207 patients with periampullary adenocarcinomas who underwent pancreaticoduodenectomy between January 1, 2001 and December 31, 2009. Clinicopathologic features were assessed, and the data were analyzed using univariate and multivariate methods. Results. In univariate analysis, perineural invasion had a strong association with 1-year mortality (OR 3.03, CI 1.42–6.47), and one lymph node (LN) increase in the LN ratio (LNR) equated with a 5-fold increase in mortality. In contrast, LN status (OR 6.42, CI 3.32–12.41) and perineural invasion (OR 5.44, CI 2.81–10.52) had the strongest associations with mortality at 3 years. Using Cox proportional hazards, perineural invasion (HR 2.61, CI 1.77–3.85) and LN status (HR 2.69, CI 1.84–3.95) had robust associations with overall mortality. Recursive partitioning analysis identified LNR as the most important risk factor for mortality at 1 and 3 years. Conclusions. Overall mortality was closely related to the LNR within the first year, while longer follow-up periods demonstrated a stronger association with perineural invasion and overall LN status. Therefore, the current staging for periampullary tumors may need to be updated to include the LNR. Jennifer K. Plichta, Anjali S. Godambe, Zachary Fridirici, Sherri Yong, James M. Sinacore, Gerard J. Abood, and Gerard V. Aranha Copyright © 2014 Jennifer K. Plichta et al. All rights reserved. Debakey Forceps Crushing Technique for Hepatic Parenchymal Transection in Liver Surgery: A Review of 100 Cases and Ergonomic Advantages Mon, 09 Jun 2014 11:47:29 +0000 http://www.hindawi.com/journals/hpb/2014/861829/ Introduction and Objective. Bleeding is an important complication in liver transections. To determine the safety and efficacy of Debakey forceps for liver parenchymal transection and its ergonomic advantages over clamp crushing method we analysed our data. Methods. We used Debakey crushing technique in 100 liver resections and analysed data for transection time, transfusion rate, morbidity, mortality, hospital stay, influence of different types of liver conditions, and ergonomi features of Debakey forceps. Results. Mean age, transection time and hospital stay of 100 patients were 52.38 ± 17.44 years, 63.36 ± 33.4 minutes, and 10.27 ± 5.7 days. Transection time, and hospital stay in patients with cirrhotic liver (130.4 ± 44.4 mins, 14.6 ± 5.5 days) and cholestatic liver (75.8 ± 19.7 mins, 16.5 ± 5.1 days) were significantly greater than in patients with normal liver (48.1 ± 20.1 mins, 6.7 ± 1.8 days) (). Transection time improved significantly with experience (first fifty versus second fifty cases—70.2 ± 31.1 mins versus 56.5 ± 34.5 mins, ). Qualitative evaluation revealed that Debakey forceps had ergonomic advantages over Kelly clamp. Conclusions. Debakey forceps crushing technique is safe and effective for liver parenchymal transection in all kinds of liver. Transection time improves with surgeon’s experience. It has ergonomic advantages over Kelly clamp and is a better choice for liver transection. Sundeep Jain, Bharat Sharma, Mitesh Kaushik, and Lokendra Jain Copyright © 2014 Sundeep Jain et al. All rights reserved. The Prognostic Significance of Lymphatics in Colorectal Liver Metastases Tue, 20 May 2014 08:59:12 +0000 http://www.hindawi.com/journals/hpb/2014/954604/ Background. Colorectal Cancer (CRC) is the most common form of cancer diagnosed in Australia across both genders. Approximately, 40%–60% of patients with CRC develop metastasis, the liver being the most common site. Almost 70% of CRC mortality can be attributed to the development of liver metastasis. This study examines the pattern and density of lymphatics in colorectal liver metastases (CLM) as predictors of survival following hepatic resection for CLM. Methods. Patient tissue samples were obtained from the Victorian Cancer Biobank. Immunohistochemistry was used to examine the spatial differences in blood and lymphatic vessel densities between different regions within the tumor (CLM) and surrounding host tissue. Lymphatic vessel density (LVD) was assessed as a potential prognostic marker. Results. Patients with low lymphatic vessel density in the tumor centre, tumor periphery, and adjacent normal liver demonstrated a significant disease-free survival advantage compared to patients with high lymphatic vessel density (, , and , resp.). Lymphatic vessel density in the tumor centre and periphery and adjacent normal liver was an accurate predictive marker of disease-free survival (). Conclusion. Lymphatic vessel density in CLM appears to be an accurate predictor of recurrence and disease-free survival. Vijayaragavan Muralidharan, Linh Nguyen, Jonathan Banting, and Christopher Christophi Copyright © 2014 Vijayaragavan Muralidharan et al. All rights reserved. Prognostic Factors for Long-Term Survival in Patients with Ampullary Carcinoma: The Results of a 15-Year Observation Period after Pancreaticoduodenectomy Sun, 02 Mar 2014 11:54:28 +0000 http://www.hindawi.com/journals/hpb/2014/970234/ Introduction. Although ampullary carcinoma has the best prognosis among all periampullary carcinomas, its long-term survival remains low. Prognostic factors are only available for a period of 10 years after pancreaticoduodenectomy. The aim of this retrospective study was to identify factors that influence the long-term patient survival over a 15-year observation period. Methods. From 1992 to 2007, 143 patients with ampullary carcinoma underwent pancreatic resection. 86 patients underwent pylorus-preserving pancreaticoduodenectomy (60%) and 57 patients underwent standard Kausch-Whipple pancreaticoduodenectomy (40%). Results. The overall 1-, 5-, 10-, and 15-year survival rates were 79%, 40%, 24%, and 10%, respectively. Within a mean observation period of 30 (0–205) months, 100 (69%) patients died. Survival analysis showed that positive lymph node involvement , lymphatic vessel invasion , intraoperative administration of packed red blood cells , an elevated CA 19-9 , jaundice , and an impaired patient condition are strong negative predictors for a reduced patient survival. Conclusions. Patients with ampullary carcinoma have distinctly better long-term survival than patients with pancreatic adenocarcinoma. Long-term survival depends strongly on lymphatic nodal and vessel involvement. Moreover, a preoperative elevated CA 19-9 proved to be a significant prognostic factor. Adjuvant therapy may be essential in patients with this risk constellation. Fritz Klein, Dietmar Jacob, Marcus Bahra, Uwe Pelzer, Gero Puhl, Alexander Krannich, Andreas Andreou, Safak Gül, and Olaf Guckelberger Copyright © 2014 Fritz Klein et al. All rights reserved. Metabolomic Analysis of Liver Tissue from the VX2 Rabbit Model of Secondary Liver Tumors Sun, 02 Mar 2014 11:17:31 +0000 http://www.hindawi.com/journals/hpb/2014/310372/ Purpose. The incidence of liver neoplasms is rising in USA. The purpose of this study was to determine metabolic profiles of liver tissue during early cancer development. Methods. We used the rabbit VX2 model of liver tumors (LT) and a control group consisting of sham animals implanted with Gelfoam into their livers (LG). After two weeks from implantation, liver tissue from lobes with and without tumor was obtained from experimental animals (LT+/LT−) as well as liver tissue from controls (LG+/LG−). Peaks obtained by Gas Chromatography-Mass Spectrometry were subjected to identification. 56 metabolites were identified and their profiles compared between groups using principal component analysis (PCA) and a mixed-effect two-way ANOVA model. Results. Animals recovered from surgery uneventfully. Analyses identified a metabolite profile that significantly differs in experimental conditions after controlling the False Discovery Rate (FDR). 16 metabolites concentrations differed significantly when comparing samples from (LT+/LT−) to samples from (LG+/LG−) livers. A significant difference was also shown in 20 metabolites when comparing samples from (LT+) liver lobes to samples from (LT−) liver lobes. Conclusion. Normal liver tissue harboring malignancy had a distinct metabolic signature. The role of metabolic profiles on liver biopsies for the detection of early liver cancer remains to be determined. R. Ibarra, J-E. Dazard, Y. Sandlers, F. Rehman, R. Abbas, R. Kombu, G-F. Zhang, H. Brunengraber, and J. Sanabria Copyright © 2014 R. Ibarra et al. All rights reserved. Preoperative Gadoxetic Acid-Enhanced MRI and Simultaneous Treatment of Early Hepatocellular Carcinoma Prolonged Recurrence-Free Survival of Progressed Hepatocellular Carcinoma Patients after Hepatic Resection Wed, 19 Feb 2014 09:58:08 +0000 http://www.hindawi.com/journals/hpb/2014/641685/ Background/Purpose. The purpose of this study was to clarify whether preoperative gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI) and simultaneous treatment of suspected early hepatocellular carcinoma (eHCC) at the time of resection for progressed HCC affected patient prognosis following hepatic resection. Methods. A total of 147 consecutive patients who underwent their first curative hepatic resection for progressed HCC were enrolled. Of these, 77 patients underwent EOB-MRI (EOB-MRI (+)) before hepatic resection and the remaining 70 patients did not (EOB-MRI (−)). Suspected eHCCs detected by preoperative imaging were resected or ablated at the time of resection for progressed HCC. Results. The number of patients who underwent treatment for eHCCs was significantly higher in the EOB-MRI (+) than in the EOB-MRI (−) (17 versus 6; ). Recurrence-free survival (1-, 3-, and 5-year; 81.4, 62.6, 48.7% versus 82.1, 41.5, 25.5%, resp., ), but not overall survival (1-, 3-, and 5-year; 98.7, 90.7, 80.8% versus 97.0, 86.3, 72.4%, resp., ), was significantly better in the EOB-MRI (+). Univariate and multivariate analyses showed that preoperative EOB-MRI was one of the independent factors significantly correlated with better recurrence-free survival. Conclusions. Preoperative EOB-MRI and simultaneous treatment of eHCC prolonged recurrence-free survival after hepatic resection. Masanori Matsuda, Tomoaki Ichikawa, Hidetake Amemiya, Akira Maki, Mitsuaki Watanabe, Hiromichi Kawaida, Hiroshi Kono, Katsuhiro Sano, Utaroh Motosugi, and Hideki Fujii Copyright © 2014 Masanori Matsuda et al. All rights reserved. A Single Centre Experience of First “One Hundred Laparoscopic Liver Resections” Tue, 11 Feb 2014 09:24:10 +0000 http://www.hindawi.com/journals/hpb/2014/930953/ Background. Laparoscopic liver resection (LLR) has emerged as an alternative procedure to open liver resection in selected patients. The purpose of this study was to describe our initial experience of 100 patients undergoing LLR. Methods. We analysed a prospectively maintained hepatobiliary database of 100 patients who underwent LLR between August 2007 and August 2012. Clinicopathological data were reviewed to evaluate surgical outcomes following LLR. Results. The median age was 64 and median BMI 27. Patients had a liver resection for either malignant lesions () or benign lesions (). Commonly performed procedures were segmentectomy/metastectomy (), left lateral sectionectomy (LLS) (), or major hepatectomy (). Complete LLR was performed in 84 patients, 9 were converted to open and 7 hand-assisted. The most common indications were CRLM (), followed by hepatic adenoma () or hepatocellular carcinoma (). The median operating time was 240 minutes and median blood loss was 250 mL. Major postoperative complications occurred in 9 patients. The median length of stay (LOS) was 5 days. One patient died within 30 days of liver resection. Conclusions. LLR is a safe and oncologically feasible procedure with comparable short-term perioperative outcomes to the open approach. However, further studies are necessary to determine long-term oncological outcomes. S. Rehman, S. K. P. John, J. J. French, D. M. Manas, and S. A. White Copyright © 2014 S. Rehman et al. All rights reserved. Combined Liver and Multivisceral Resections Tue, 11 Feb 2014 00:00:00 +0000 http://www.hindawi.com/journals/hpb/2014/976546/ Background. Combined liver and multivisceral resections are infrequent procedures, which demand extensive experience and considerable surgical skills. Methods. An electronic search of literature related to this topic published before June 2013 was performed. Results. There is limited scientific evidence of the feasibility and clinical outcomes of these complex procedures. The majority of these cases are simultaneous resections of colorectal tumors with liver metastases. Combined liver and multivisceral resections can be performed with acceptable postoperative morbidity and mortality rates only in carefully selected patients. Conclusion. Lack of experience in these aggressive surgeries justifies a careful selection of patients, considering their comorbidities. Martin de Santibañes, Agustin Dietrich, and Eduardo de Santibañes Copyright © 2014 Martin de Santibañes et al. All rights reserved. Pancreatic Resections in Renal Failure Patients: Is It Worth the Risk? Sun, 09 Feb 2014 13:41:37 +0000 http://www.hindawi.com/journals/hpb/2014/938251/ Background. Chronic kidney disease affects 20 million US patients, with nearly 600,000 on dialysis. Long-term survival is limited and the risk of complex pancreatic surgery in this group is questionable. Previous studies are limited to case reports and small case series and a large database may help determine the true risk of pancreatic surgery in this population. Methods. The American College of Surgeons National Surgical Quality Improvement Program database was queried (2005–2011) for patients who underwent pancreatic resection. Renal failure was defined as the clinical condition associated with rapid, steadily increasing azotemia (rise in BUN) and increasing creatinine above 3 mg/dL. Operative trends and short-term outcomes were reviewed for those with and without renal failure (RF). Results. In 18,533 patients, 28 had RF. There was no difference in wound infections, neurologic or cardiovascular complications. Compared to non-RF patients, those with RF had more unplanned intubation (OR 4.89, 95% CI 1.85–12.89), bleeding requiring transfusion (OR 3.12, 95% CI 1.37–14.21), septic shock (OR 8.86, 95% CI 3.75–20.91), higher 30-day mortality (21.4% versus 2.3%, ) and longer hospital stay (23 versus 12 days, ). Conclusions. RF patients have much higher morbidity and mortality after pancreatic resections and surgeons should consider this before proceeding. K. S. Norman, S. R. Domingo, and L. L. Wong Copyright © 2014 K. S. Norman et al. All rights reserved. Liver Resections of Isolated Liver Metastasis in Breast Cancer: Results and Possible Prognostic Factors Sun, 19 Jan 2014 00:00:00 +0000 http://www.hindawi.com/journals/hpb/2014/893829/ Background. Breast cancer liver metastasis is a hematogenous spread of the primary tumour. It can, however, be the expression of an isolated recurrence. Surgical resection is often possible but controversial. Methods. We report on 29 female patients treated operatively due to isolated breast cancer liver metastasis over a period of six years. Prior to surgery all metastases appeared resectable. Liver metastasis had been diagnosed 55 (median, range 1–177) months after primary surgery. Results. Complete resection of the metastases was performed in 21 cases. The intraoperative staging did not confirm the preoperative radiological findings in 14 cases, which did not generally lead to inoperability. One-year survival rate was 86% in resected patients and 37.5% in nonresected patients. Significant prognostic factors were R0 resection, low T- and N-stages as well as a low-grade histopathology of the primary tumour, lower number of liver metastases, and a longer time interval between primary surgery and the occurrence of liver metastasis. Conclusions. Complete resection of metastases was possible in three-quarters of the patients. Some of the studied factors showed a prognostic value and therefore might influence indication for resection in the future. Malte Weinrich, Christel Weiß, Jochen Schuld, and Bettina M. Rau Copyright © 2014 Malte Weinrich et al. All rights reserved. Venous Outflow Reconstruction in Adult Living Donor Liver Transplant: Outcome of a Policy for Right Lobe Grafts without the Middle Hepatic Vein Mon, 30 Dec 2013 17:17:20 +0000 http://www.hindawi.com/journals/hpb/2013/280857/ Introduction. The difficulty and challenge of recovering a right lobe graft without MHV drainage is reconstructing the outflow tract of the hepatic veins. With the inclusion or the reconstruction of the MHV, early graft function is satisfactory. The inclusion of the MHV or not in the donor’s right lobectomy should be based on sound criteria to provide adequate functional liver mass for recipient, while keeping risk to donor to the minimum. Objective. Reviewing the results of a policy for right lobe grafts transplant without MHV and analyzing methods of venous reconstruction related to outcome. Materials and Methods. We have two groups Group A (with more than one HV anast.) () and Group B (single HV anast.) (). Both groups were compared regarding indications for reconstruction, complications, and operative details and outcomes, besides describing different modalities used for venous reconstruction. Results. Significant increase in operative details time in Group A. When comparison came to complications and outcomes in terms of laboratory findings and overall hospital stay, there were no significant differences. Three-month and one-year survival were better in Group A. Conclusion. Adult LDLT is safely achieved with better outcome to recipients and donors by recovering the right lobe without MHV, provided that significant MHV tributaries (segments V, VIII more than 5 mm) are reconstructed, and any accessory considerable inferior right hepatic veins (IRHVs) or superficial RHVs are anastomosed. Mohamed Ghazaly, Mohamad T. Badawy, Hosam El-Din Soliman, Magdy El-Gendy, Tarek Ibrahim, and Brian R. Davidson Copyright © 2013 Mohamed Ghazaly et al. All rights reserved. Partial Preservation of Segment IV Confers No Benefit When Performing Extended Right Hepatectomy for Colorectal Liver Metastases Wed, 11 Dec 2013 11:59:33 +0000 http://www.hindawi.com/journals/hpb/2013/458641/ Introduction. Reducing the volume of resected liver parenchyma may lead to lower morbidity and mortality. The aim of this study was to determine whether partial preservation of segment IV leads to improved outcomes when undertaking extended right hepatectomy for colorectal liver metastases (CRLM). Materials and Methods. A retrospective analysis of patients undergoing right-sided hepatectomy for CRLM was performed. Rates of 90-day mortality and organ dysfunction were compared in 117 patients undergoing right hepatectomy , partially extended right hepatectomy with preservation of part of segment IV , and fully extended right hepatectomy . Results. The 90-day mortality rate of those undergoing right hepatectomy (3/85) was similar to that of those undergoing extended right hepatectomy (0/12) but lower than that of those undergoing partially extended right hepatectomy (4/20) . The rates of hepatic and renal dysfunction were similar between patients undergoing right hepatectomy, partially extended or extended hepatectomy. Discussion. Preservation of part of segment IV confers little clinical benefit when performing extended right hepatectomy for CRLM. M. G. Wiggans, S. Fisher, H. Adwan, S. Aroori, M. J. Bowles, and D. A. Stell Copyright © 2013 M. G. Wiggans et al. All rights reserved. Renal Dysfunction Is an Independent Risk Factor for Mortality after Liver Resection and the Main Determinant of Outcome in Posthepatectomy Liver Failure Tue, 05 Nov 2013 15:51:55 +0000 http://www.hindawi.com/journals/hpb/2013/875367/ Introduction. The aim of this study was to assess the interaction of liver and renal dysfunction as risk factors for mortality after liver resection. Materials and Methods. A retrospective analysis of 501 patients undergoing liver resection in a single unit was undertaken. Posthepatectomy liver failure (PHLF) was defined according to the International Study Group of Liver Surgery (ISGLS) definition (assessed on day 5) and renal dysfunction according to RIFLE criteria. 90-day mortality was recorded. Results. Twenty-three patients died within 90 days of surgery (4.6%). The lowest mortality occurred in patients without evidence of PHLF or renal dysfunction (2.7%). The mortality rate in patients with isolated PHLF or renal dysfunction was 20% compared to 45% in patients with both. Diabetes (), renal dysfunction (), and PHLF on day 5 () were independent predictors of 90-day mortality. Discussion. PHLF and postoperative renal dysfunction are independent predictors of 90-day mortality following liver resection but the predictive value for mortality is significantly higher when failure of both organ systems occurs simultaneously. M. G. Wiggans, G. Shahtahmassebi, M. J. Bowles, S. Aroori, and D. A. Stell Copyright © 2013 M. G. Wiggans et al. All rights reserved. Selective Interarterial Radiation Therapy (SIRT) in Colorectal Liver Metastases: How Do We Monitor Response? Tue, 29 Oct 2013 18:15:35 +0000 http://www.hindawi.com/journals/hpb/2013/570808/ Radioembolisation is a way of providing targeted radiotherapy to colorectal liver metastases. Results are encouraging but there is still no standard method of assessing the response to treatment. This paper aims to review the current experience assessing response following radioembolisation. A literature review was undertaken detailing radioembolisation in the treatment of colorectal liver metastases comparing staging methods, criteria, and response. A search was performed of electronic databases from 1980 to November 2011. Information acquired included year published, patient numbers, resection status, chemotherapy regimen, criteria used to stage disease and assess response to radioembolisation, tumour markers, and overall/progression free survival. Nineteen studies were analysed including randomised controlled trials, clinical trials, meta-analyses, and case series. There is no validated modality as the method of choice when assessing response to radioembolisation. CT at 3 months following radioembolisation is the most frequently modality used to assess response to treatment. PET-CT is increasingly being used as it measures functional and radiological aspects. RECIST is the most frequently used criteria. Conclusion. A validated modality to assess response to radioembolisation is needed. We suggest PET-CT and CEA pre- and postradioembolisation at 3 months using RECIST 1.1 criteria released in 2009, which includes criteria for PET-CT, cystic changes, and necrosis. D. Hipps, F. Ausania, D. M. Manas, J. D. G. Rose, and J. J. French Copyright © 2013 D. Hipps et al. All rights reserved. Comparison of Ranson, Glasgow, MOSS, SIRS, BISAP, APACHE-II, CTSI Scores, IL-6, CRP, and Procalcitonin in Predicting Severity, Organ Failure, Pancreatic Necrosis, and Mortality in Acute Pancreatitis Tue, 24 Sep 2013 11:23:59 +0000 http://www.hindawi.com/journals/hpb/2013/367581/ Background. Multifactorial scorings, radiological scores, and biochemical markers may help in early prediction of severity, pancreatic necrosis, and mortality in patients with acute pancreatitis (AP). Methods. BISAP, APACHE-II, MOSS, and SIRS scores were calculated using data within 24 hrs of admission, whereas Ranson and Glasgow scores after 48 hrs of admission; CTSI was calculated on day 4 whereas IL-6 and CRP values at end of study. Predictive accuracy of scoring systems, sensitivity, specificity, and positive and negative predictive values of various markers in prediction of severe acute pancreatitis, organ failure, pancreatic necrosis, admission to intensive care units and mortality were calculated. Results. Of 72 patients, 31 patients had organ failure and local complication classified as severe acute pancreatitis, 17 had pancreatic necrosis, and 9 died (12.5%). Area under curves for Ranson, Glasgow, MOSS, SIRS, APACHE-II, BISAP, CTSI, IL-6, and CRP in predicting SAP were 0.85, 0.75, 0.73, 0.73, 0.88, 0.80, 0.90, and 0.91, respectively, for pancreatic necrosis 0.70, 0.64, 0.61, 0.61, 0.68, 0.61, 0.75, 0.86, and 0.90, respectively, and for mortality 0.84, 0.83, 0.77, 0.76, 0.86, 0.83, 0.57, 0.80, and 0.75, respectively. Conclusion. CRP and IL-6 have shown a promising result in early detection of severity and pancreatic necrosis whereas APACHE-II and Ranson score in predicting AP related mortality in this study. Ajay K. Khanna, Susanta Meher, Shashi Prakash, Satyendra Kumar Tiwary, Usha Singh, Arvind Srivastava, and V. K. Dixit Copyright © 2013 Ajay K. Khanna et al. All rights reserved. A Randomized Clinical Trial Comparing the Effect of Different Haemostatic Agents for Haemostasis of the Liver after Hepatic Resection Tue, 17 Sep 2013 08:49:20 +0000 http://www.hindawi.com/journals/hpb/2013/587608/ Introduction. Operative blood loss is still a great obstacle to liver resection, and various topical hemostatic agents were introduced to reduce it. The aim of the current study is to evaluate effects of 3 different types of these agents. Methods. In this randomized clinical trial, 45 patients undergoing liver resection were assigned to receive TachoSil, Surgicel, and Glubran 2 for controlling bleeding. Intraoperative and postoperative findings were compared between groups. Results. Postoperative bleeding (0 versus 33.3%, ) and drainage volume first day after surgery ( versus  mL, ) were significantly higher in Surgicel than in TachoSil group. Postoperative complications included bile leak (3 cases in Surgicel, 1 case in TachoSil and Glubran 2), noninfectious collection (2 cases in TachoSil and Surgicel and 1 case in Glubran 2), perihepatic abscess, and massive hematoma around hepatectomy site both in Surgicel group. There was no death during the study period. Conclusion. Due to higher complications in Surgicel group, its application as hemostatic agent after liver resection is not recommended. Better results in TachoSil in comparison to the other two are indicative of its better efficacy and superiority in controlling hemostasis. Farzad Kakaei, Mir Salim Seyyed Sadeghi, Behnam Sanei, Shahryar Hashemzadeh, and Afshin Habibzadeh Copyright © 2013 Farzad Kakaei et al. All rights reserved. Intraportal versus Systemic Pentoxifylline Infusion after Normothermic Liver Ischemia: Effects on Regional Blood Flow Redistribution and Hepatic Ischemia-Reperfusion Injury Thu, 29 Aug 2013 16:12:28 +0000 http://www.hindawi.com/journals/hpb/2013/689835/ Pentoxifylline (PTX) has been shown to have beneficial effects on microcirculatory blood flow. In this study we evaluate the potential hemodynamic and metabolic benefits of PTX during hepatic ischemia. We also test the hypothesis that portal PTX infusion can minimize the I/R injury when compared to systemic infusion. Methods. Twenty-four dogs ( kg) were subjected to portal triad occlusion (PTO) for 45 min. The animals were assigned to 3 groups: CT (control, PTO, ), PTX-syst (PTO + 25 mg/Kg of PTX IV, ), and PTX-pv (PTO + 25 mg/Kg of PTX in the portal vein, ). Animals were followed for 120 min. Systemic hemodynamics, gastrointestinal tract perfusion, oxygen-derived variables, and liver enzymes were evaluated throughout the experiment. Results. Animals treated with PTX presented significantly higher CO in the first hour after reperfusion, when compared to the CT (~3.7 vs. 2.1 L/min, ). Alanine aminotransferase (ALT) was similar in the PTX groups two hours after reperfusion but significantly higher in the CT (227 vs. ~64 U/L, ). Conclusion. PTX infusion was associated with hemodynamic benefits and was able to minimize liver injury during normothermic hepatic I/R. However, local PTX infusion was not associated with any significant advantage over systemic route. Edson A. Ribeiro, Luiz F. Poli-de-Figueiredo, Rodrigo Vincenzi, Flavio H. F. Galvao, Nelson Margarido, Mauricio Rocha-e-Silva, and Ruy J. Cruz Jr. Copyright © 2013 Edson A. Ribeiro et al. All rights reserved. The Preoperative Assessment of Hepatic Tumours: Evaluation of UK Regional Multidisciplinary Team Performance Thu, 22 Aug 2013 12:14:09 +0000 http://www.hindawi.com/journals/hpb/2013/861681/ Introduction. In the UK, patients where liver resection is contemplated are discussed at hepatobiliary multidisciplinary team (MDT) meetings. The aim was to assess MDT performance by identification of patients where radiological and pathological diagnoses differed. Materials and Methods. A retrospective review of a prospectively maintained database of all cases undergoing liver resection from March 2006 to January 2012 was performed. The presumed diagnosis as a result of radiological investigation and MDT discussion is recorded at the time of surgery. Imaging was reviewed by specialist gastrointestinal radiologists, and resultswereagreedonby consensus. Results. Four hundred and thirty-eight patients were studied. There was a significant increase in the use of preoperative imaging modalities () but no change in the rate of discrepant diagnosis over time. Forty-two individuals were identified whose final histological diagnosis was different to that following MDT discussion (9.6%). These included 30% of patients diagnosed preoperatively with hepatocellular carcinoma and 25% with cholangiocarcinoma of a major duct. Discussion. MDT assessment of patients preoperatively is accurate in terms of diagnosis. The highest rate of discrepancies occurred in patients with focal lesions without chronic liver disease or primary cancer, where hepatocellular carcinoma was overdiagnosed and peripheral cholangiocarcinoma underdiagnosed, where particular care should be taken. Additional care should be taken in these groups and preoperative multimodality imaging considered. M. G. Wiggans, S. A. Jackson, B. M. T. Fox, J. D. Mitchell, S. Aroori, M. J. Bowles, E. M. Armstrong, J. F. Shirley, and D. A. Stell Copyright © 2013 M. G. Wiggans et al. All rights reserved. MDCT Imaging Findings of Liver Cirrhosis: Spectrum of Hepatic and Extrahepatic Abdominal Complications Tue, 06 Aug 2013 09:45:06 +0000 http://www.hindawi.com/journals/hpb/2013/129396/ Hepatic cirrhosis is the clinical and pathologic result of a multifactorial chronic liver injury. It is well known that cirrhosis is the origin of multiple extrahepatic abdominal complications and a markedly increased risk of hepatocellular carcinoma (HCC). This tumor is the sixth most common malignancy worldwide and the third most common cause of cancer related death. With the rising incidence of HCC worldwide, awareness of the evolution of cirrhotic nodules into malignancy is critical for an early detection and treatment. Adequate imaging protocol selection with dynamic multiphase Multidetector Computed Tomography (MDCT) and reformatted images is crucial to differentiate and categorize the hepatic nodular dysplasia. Knowledge of the typical and less common extrahepatic abdominal manifestations is essential for accurately assessing patients with known or suspected hepatic disease. The objective of this paper is to illustrate the imaging spectrum of intra- and extrahepatic abdominal manifestations of hepatic cirrhosis seen on MDCT. Guillermo P. Sangster, Carlos H. Previgliano, Mathieu Nader, Elisa Chwoschtschinsky, and Maureen G. Heldmann Copyright © 2013 Guillermo P. Sangster et al. All rights reserved. An Evaluation of Neoadjuvant Chemoradiotherapy for Patients with Resectable Pancreatic Ductal Adenocarcinoma Thu, 20 Jun 2013 11:35:00 +0000 http://www.hindawi.com/journals/hpb/2013/298726/ Aims. The aim of this study is to compare our results of preoperative chemotherapy followed by pancreaticoduodenectomy (PD) with those of surgery alone in patients with localized resectable pancreatic ductal adenocarcinoma (PDAC). Methods. Outcome data for 112 patients of resectable PDAC who received preoperative chemoradiotherapy followed by PD (group I) between January 2004 and April 2010 were retrospectively analyzed and were compared with selected 120 patients who underwent PD alone (group II) in the same period. Results. Patients in group I had an incidence of locoregional recurrence of 17.1% compared to 30.8% in group II (). There were no statistically significant differences in postoperative morbidity (27.7% versus 30.8%) and mortality (2.67% versus 3.33%). The 1-, 2-, and 3-year survival rates were estimated at 82.1%, 54%, and 28%, respectively, with NCRT and 65.8%, 29.1%, and 10% without (). Nevertheless, preoperative chemotherapy did not reduce the 1-, 3-, and 5-year disease-free survival rates, which were estimated at 58%, 36.6%, and 12.5% with NCRT and 51.7%, 18.3%, and 7.5% without (). Conclusions. The treatment of NCRT followed by PD in patients with PDAC has a significantly lower rate of locoregional recurrence and a longer overall survival than those with surgery alone. Hui Jiang, Chi Du, Mingwei Cai, Hai He, Cheng Chen, Jianguo Qiu, and Hong Wu Copyright © 2013 Hui Jiang et al. All rights reserved. Aggressive Treatment of Patients with Metastatic Colorectal Cancer Increases Survival: A Scandinavian Single-Center Experience Thu, 06 Jun 2013 09:49:45 +0000 http://www.hindawi.com/journals/hpb/2013/727095/ Background. We examined overall and disease-free survivals in a cohort of patients subjected to resection of liver metastasis from colorectal cancer (CRLM) in a 10-year period when new treatment strategies were implemented. Methods. Data from 239 consecutive patients selected for liver resection of CRLM during the period from 2002 to 2011 at a single center were used to estimate overall and disease-free survival. The results were assessed against new treatment strategies and established risk factors. Results. The 5-year cumulative overall and disease-free survivals were 46 and 24%. The overall survival was the same after reresection, independently of the number of prior resections and irrespectively of the location of the recurrent disease. The time intervals between each recurrence were similar (11 1 months). Patients with high tumor load given neoadjuvant chemotherapy had comparable survival to those with less extensive disease without neoadjuvant chemotherapy. Positive resection margin or resectable extrahepatic disease did not affect overall survival. Conclusion. Our data support that one still, and perhaps to an even greater extent, should seek an aggressive therapeutic strategy to achieve resectable status for recurrent hepatic and extrahepatic metastases. The data should be viewed in the context of recent advances in the understanding of cancer biology and the metastatic process. Kristoffer Watten Brudvik, Simer Jit Bains, Lars Thomas Seeberg, Knut Jørgen Labori, Anne Waage, Kjetil Taskén, Einar Martin Aandahl, and Bjørn Atle Bjørnbeth Copyright © 2013 Kristoffer Watten Brudvik et al. All rights reserved.